Fillable Form PERS-60 Rev. 4/07: APPLICANTS AFFIDAVIT OF DISABILITY (Unified Judicial System - State of Alabama)

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Form PERS-60 Rev. 4/07: APPLICANTS AFFIDAVIT OF DISABILITY (Unified Judicial System - State of Alabama)

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State of Alabama
Unified Judicial System
Form PERS-60 Rev. 4/07
APPLICANT’S
AFFIDAVIT OF DISABILITY
(Type or Print)
Name:
Present Position:
Home Address:
(Number) (Street) (City) (State) (Zip Code)
Telephone Number:
Home: Work:
Date of Birth:
Spouse’s Date of Birth:
Date of onset of illness or injury causing present disability:
Are you now totally disabled and unable to work?
If “yes” give date of disability:
Date last worked:
Nature of illness or injury upon which disability retirement is being claimed:
Form PERS-60 (back)
APPLICANTS AFFIDAVIT OF DISABILITY
Physicians consulted since onset of disability:
Name Address
Date of first treatment:
Physician:
If hospitalized for disabling disease/illness/injury give names of hospitals:
Date your current term ends:
Last election in which you were a candidate for office:
Did you lose?
THE ABOVE ANSWERS ARE TRUE AND COMPLETE ACCORDING TO THE BEST OF MY KNOWLEDGE AND BELIEF.
NOTE: Any person who knowingly files an Affidavit/Statement of Claim containing
any false or misleading information is subject to criminal and civil penalties
Sworn to and subscribed before me this
Date:
Applicant’s Signature
Notary Public Applicant’s Name (please print or type)
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Form PERS-60 Rev. 407: APPLICANTS AFFIDAVIT OF DISABILITY (Unified Judicial System - State of Alabama)

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Completed 16 April 2021

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